The ramifications of armed conflicts on the populations involved are well established. Conflicts between countries inevitably result in widespread human suffering, impacting families, health, the economy, and the environment. The effects of conflicts on health can include both physical and psychological harm to civilian populations within the conflict zone (1, 2). However, the impact of conflicts on health-related issues in populations outside the conflict zone requires further investigation.

In a review of mind–body interaction, Mallorquí-Bagué and colleagues (3) define anxiety as an emotional state influenced by psychological, physical, and behavioral factors. The DSM-5 (4) categorizes anxiety disorders into twelve disorders, including generalized anxiety disorder (GAD). GAD is characterized by excessive and persistent worry regarding daily events over time, which can interfere with daily activities, impair social and occupational performance, and disrupt relationships with others. The primary symptoms of GAD encompass restlessness or being on edge, easily becoming fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbances. These symptoms must be present independently of any medical conditions, mental health disorders, or substance use.

Research studies have found a positive relationship between GAD and the presence of somatic symptoms, as well as a negative relationship between GAD and wellbeing in various contexts, including hospitalization, natural disasters, COVID-19, and conflicts (5–13). Somatic symptoms refer to physical sensations that may disrupt daily functioning, such as headaches, musculoskeletal pain, abdominal aches, trouble sleeping, and fatigue, which cannot be explained by medical conditions (9, 14, 15). On the other hand, wellbeing is a holistic positive state encompassing emotions, free from anxiety and depression. The World Health Organization (WHO) considers wellbeing as a determinant of an individual’s and society’s health, influenced by multiple factors such as physical, environmental, social, emotional, psychological, activity participation, economic, and resilience (16–18).

Most studies on conflict primarily investigate health-related issues, such as mental disorders, somatic symptoms, and wellbeing, among populations within the conflict zones (19, 20). However, health-related issues among populations around, near, or within the geographical area of the conflict zones are rarely explored (12, 13, 21). There are various factors that may influence the health of these populations, including social media platforms, news, economic, environmental, cultural, and political ties to the conflict zones. Therefore, the objective of the study was to examine generalized anxiety disorder, associated somatic symptoms, and wellbeing among the Kuwait population during the Gaza Conflict of 2023, while also exploring the provoking factors.

Kuwait, with an area of 17,820 square kilometers (6,880 square miles), has a population of over 4.9 million, of which 1.5 million (32%) are Kuwaiti (22). Geographically located in West Asia and geopolitically in the Middle East, Kuwait adopts Arabic as its official language and Islam as its official religion. It lies in the northwestern part of the Arabian Gulf, bordered by Iraq to the northwest and Saudi Arabia to the south and southwest. The distance between Kuwait and the Gaza Conflict is approximately 1,270 kilometers (789 miles), crossing south of Iraq, north of Saudi Arabia, and Jordan. Kuwait shares geographical, geocultural, and geopolitical factors with the people in the conflict zone, including location, trade, political alliances, religion, language, and culture. The Gaza Conflict commenced on October 7th, 2023.

Two thousand seventy-three (2,273) participants completed the survey. Two hundred and ninety-four surveys were excluded from the study because the participants were under the age of 18 and had mental disorders or chronic physical conditions. The final inclusion was 1979 participants. Of these, 1,582 (80%) were females, and 397 (20%) were males. The ages ranged from 18 to 89, with a mean of 34.89 ± 13.04 years (Table 1).

Regarding the Gaza conflict, 88% of the participants indicated following news, in which 73% reported mainly following the news through social media platforms. Due to the association between anxiety, somatic symptoms, and wellbeing, most of those participants experience moderate to severe anxiety and somatic symptoms and poor to depressive wellbeing (Figure 1). Only, 12% of the participants were not interested in following the Gaza Conflict compared to 88% at least spent 30 min per day. Within all the duration categories of following the conflict news (30, 60, 90, 120 min), participants experience high percentages of moderate to severe anxieties and somatic symptoms and poor to depressive wellbeing (Figure 2). Moreover, more than 60% of the participants reported being preoccupied with the Gaza Conflict during work, social activities, and rest/leisure activities. In addition, 84% of participants described fluctuating emotions and feelings throughout the day. Over again, those participants experience high levels of anxieties, somatic symptoms, and poor to depressive wellbeing (Figure 3). Most of the participants (>70%) expressed a moderate level of current insecurity (μ = 5.29 ± 2.89) and future fears (μ = 5.35 ± 3.01) with high percentages of anxieties, somatic symptoms, and poor to depressive wellbeing (Figure 4).

The participants reported moderate anxiety and somatic symptoms on GAD-7 (μ = 10.20 ± 4.48 with CI (95%) = 10.00–10.40) and mPHQ-15 (μ = 11.12 ± 6.39 with CI (95%) = 10.84–11.40), and they exhibited fair wellbeing (μ = 53.35 ± 21.82 with CI (95%) = 52.39–54.31). Table 2 shows the GAD-7, mPHQ-15, and WHO-5 scores. Spearman’s correlation coefficient showed a large positive correlation between the GAD-7 and mPHQ-15 (r(1977) = 0.52, p < 0.0001). Therefore, the effect size for anxiety (r² = 0.27) indicated that a large portion of the variability in somatic symptoms (27%) was accounted for by the level of anxiety that the participants experienced. Also, Spearman’s correlation coefficient showed a medium negative correlation between the GAD-7 and WHO-5 (r(1977) = −0.36, p < 0.0001) with the medium effect size r² = 0.13 (13%), and a medium negative correlation between the mPHQ-15 and WHO-5 (r(1977) = −0.27, p < 0.0001) with the effect size r² = 0.07 (7%). Spearman’s correlation coefficient showed a small positive correlation between the GAD-7 and current feelings of insecurity, r(1977) = 0.25, p < 0.0001 with the effect size r² = 0.06 (6%), and a medium positive correlation between GAD-7 and future fears, r(1979) = 0.30, p < 0.0001 with the small effect size r² = 0.09 (9%).

The findings revealed a medium significant association between the variable fluctuation of emotions and feelings throughout the day and GAD-7 levels (Χ²(3) = 319.67, p < 0.0001, V = 0.402), a medium significant association with mPHQ-15 levels (Χ²(3) = 218.47, p < 0.0001, V = 0.332), and a small significant association with WHO-5 levels (Χ²(4) = 93.14, p < 0.0001, V = 0.217). Also, the findings revealed a medium significant association between the variable current feelings of insecurity due to the Gaza Conflict and GAD-7 levels (Χ²(3) = 193.06, p < 0.0001, V = 0.312), a small significant association with mPHQ-15 levels (Χ²(3) = 110.15, p < 0.0001, V = 0.236), and a small significant association with WHO-5 levels (Χ²(4) = 55.96, p < 0.0001, V = 0.168). Moreover, the findings revealed a medium significant association between the variable gender and mPHQ-15 levels (Χ²(3) = 254.67, p < 0.0001, V = 0.359) (Table 3).

Anxiety has been associated with war among people living in the conflict zone (20). However, anxiety has been rarely investigated among people living in the region around or near the conflict zone. This study aimed to explore anxiety and risk factors due to the Gaza conflict among people living in Kuwait.

This study highlights that participants experienced moderate levels of generalized anxiety disorder (GAD), with 52% reporting moderate to severe anxiety symptoms. The most common indicators, as measured by the GAD-7, included feeling nervous, anxious, or on edge; excessive worrying; difficulty relaxing; and becoming easily annoyed. These findings are consistent with prior research linking GAD to somatic symptoms, diminished wellbeing, feelings of insecurity, and future fears.

The interpretation of these results relies on the DSM-IV criteria, which were chosen due to their longstanding utility in identifying and categorizing anxiety severity in both clinical and research settings. Despite the availability of DSM-V criteria, DSM-IV remains a valid reference in contexts where established benchmarks are essential for comparing historical data or aligning with widely used assessment tools, such as the GAD-7.

From a clinical perspective, moderate-to-severe anxiety, as defined by the DSM-IV, can significantly impact social and occupational functioning. This underscores the importance of addressing the potential challenges faced by participants, including impaired interpersonal relationships and reduced productivity. Professional medical interventions, such as cognitive-behavioral therapy or pharmacological treatment, are recommended for those experiencing severe anxiety symptoms to improve quality of life and mitigate the risk of long-term complications. The association found in this study between the GAD-7 and the duration of following news about the Gaza Conflict, current feelings of insecurity, and future fears may explain participants’ anxiety, such as feeling anxious and afraid, worrying too much, annoyance, and irritation. Moreover, the National Institute of Mental Health (31) highlights that GAD interferes with activities of daily living, such as work/school performance, productivity, and relationships. Similarly, our findings showed that most participants were preoccupied with the Gaza Conflict during work and study, social activities, and rest and leisure. In addition, many participants (88%) followed the news on the Gaza Conflict, with 20% spending over 90 min a day following the news on the conflict. Likewise, Khansa and colleagues (32) emphasized that increased anxiety is associated with work impairment, diminished work productivity, and poor quality of life.

We believe that the smartphones’ easy and timeless use plays an influential role in continuous access to all sorts of written and visual news, information, and content about a conflict. Terry and colleagues (33) conclude that during public crises, activities and communications on social media platforms intensify to the point of affecting public health. Greenglass et al. (12), Malecki et al. (13), Riad et al. (21), and Mărcău et al. (34) underlined that Russia-Ukraine war news increased anxiety symptoms among adult populations in Germany, Poland, the Czech Republic, and Romania. In addition, Mărcău et al. (34) and Mejia and colleagues (35) highlighted that people were experiencing severe anxiety, depression, and stress, which were associated with the fear of breaking out of world war or using nuclear weapons during the Russia-Ukraine conflict. Additionally, the spread of fake news, misinformation, and propaganda on news and social media platforms can exacerbate feelings of fear, anger, worry, and frustration. Continuing the risk of daily following the news, preoccupation with the region’s insecurity, and fear of future expansion of the conflict might negatively affect work–study performance, productivity, and relationships. Levin et al. (20) discussed that continued and increased anxiety symptoms in a dose–response manner did limit the performance in daily activities. Examining the continuance of anxiety, Damsa et al. (36) and Pejic et al. (37), through neuroimaging studies, highlighted that the amygdala, anterior cingulate cortex, and insula may contribute to the progression and persistence of anxiety symptoms in individuals.

Based on the mPHQ-15 results, most participants experienced moderate-to-severe somatic symptoms. The most reported somatic symptoms were stomach pain, back pain, headaches, fatigue, low energy, trouble sleeping, and menstrual cramps. Moreover, most of the participants fell at the lower levels of wellbeing, with an average (=54) borderline to poor (≤50). Sleep troubles, restlessness, tension, and finding fewer exciting things to do were most frequently reported in the assessment of wellbeing. In the present study, an increase in GAD was associated with an increase in somatic symptoms and a decrease in wellbeing.

The DSM-V (4), NIMH (38), and National Health Services (NHS) (39) describe several physical symptoms to identify anxiety, including headaches, stomachaches, muscle tension, sleep disturbances, pain, fatigue, dizziness, and shortness of breath, which correspond to the somatic symptoms of the mPHQ-15. Using these two diagnostic frameworks together enhances the depth and applicability of the findings. The DSM-V criteria anchor the study in a structured diagnostic tradition, while the NIMH guidelines provide a lens for interpreting the complexities of anxiety in the participants. The relationship between anxiety and the somatic symptoms as well as wellbeing in our study paralleled the findings in other studies during natural disasters, COVID-19, and conflicts (5, 9, 11, 40–45). This relationship supports the biopsychosocial model of health, which posits that psychological factors can significantly impact physical health. Furthermore, this relationship is in line with the WHO’s definition of health, which includes not only the absence of disease but also a state of complete physical, mental, and social wellbeing (16). Moreover, high engagement with news about the conflict, as reported by 88% of participants, is a notable factor that might contribute to the psychological burden experienced by the participants. In addition, more than 60% of the participants were preoccupied with conflicts during work, social, and leisure activities, which could significantly disrupt their daily functioning and quality of life. The relationship found between factors, such as the duration of following the news, preoccupation with the conflict, fluctuation of emotions, current feelings of insecurity, and future fears with the PHQ-15 and WHO-5, could negatively influence the somatic symptoms and wellbeing of the participants. Even though the participants live far away, it is possible that shared Middle Eastern geocultural characteristics, such as language, religion, race, ethnicity, culture, and region, played a crucial role in relating and sympathizing with people in the conflict zone, which might have given rise to GAD and its association with the emergence of somatic symptoms and decline in wellbeing.

The Spearman correlations calculated between GAD-7, mPHQ-15, and WHO-5 provide valuable insights into the relationships among anxiety, somatic symptoms, and wellbeing. However, the discussion could benefit from a deeper exploration of why specific correlations were small or medium. For instance, the observed medium correlation between somatic symptoms and wellbeing might be contextualized within the broader literature, which suggests that somatic symptoms can manifest independently of subjective wellbeing levels due to cultural, psychosocial, or physiological factors (46). Such findings underscore the complexity of these relationships and highlight the need for more significant investigations that consider potential mediators or moderators.

The discussion on the causality between media consumption and increased anxiety should also be clarified. Given the cross-sectional nature of the study, causality cannot be inferred, as the temporal sequence of events is not established. While media consumption may be associated with heightened anxiety levels, the directionality and underlying mechanisms require further investigation through longitudinal or experimental designs. Furthermore, the role of social media in exacerbating anxiety warrants expanded discussion. Misinformation or sensationalized content on social platforms can amplify fear and uncertainty, particularly during crises, contributing to the heightened prevalence of anxiety symptoms. This phenomenon aligns with existing literature highlighting the detrimental psychological impact of media sensationalism. Addressing this issue through targeted public health interventions, such as media literacy campaigns and the promotion of reliable information sources, could mitigate these effects. Policy recommendations aimed at regulating the dissemination of misinformation and encouraging responsible media practices should also be considered to safeguard public mental health.

Most participants reported moderate-to-severe anxiety, somatic symptoms, and borderline wellbeing. Significant associations were found between anxiety, somatic symptoms, and wellbeing. The duration of news following, current feelings of insecurity, future fear, and fluctuating emotions were the primary risk factors. Future studies investigating the effectiveness of various therapeutic interventions in conflict-affected populations are warranted. Therefore, the global call for public intervention programs that are culturally sensitive and context-specific is a priority.